Health Secretary James Murray has promised to publish an action plan by December in response to a damning independent review that found 156 babies and six mothers died as a result of substandard care at Nottingham University Hospitals National Health Service Trust over 13 years. But the review’s chair, Donna Ockenden, issued a stark warning: “We do not have the luxury of six months to develop an action plan.”
The independent review, published June 24, 2026, represents the largest maternity scandal in NHS history. Compiled by Ockenden, a senior midwife who also led a similar inquiry into the Shrewsbury and Telford Hospital NHS Trust, the report drew on the experiences of 2,500 families and documented failures so severe that all 156 infant deaths and six maternal deaths were classified as avoidable.
Leaders were repeatedly warned of maternity problems but brushed them under the carpet. Half of the senior executives at Nottingham University Hospitals refused to co-operate with the review.
Systemic Failures and a Dangerous Ideology
Hundreds more mothers and babies survived their ordeals but were left with serious, lasting injuries, including brain damage. Many women left the hospital traumatized, with a number later diagnosed with post-traumatic stress disorder.
A central theme running through the review was an institutional fixation on so-called normal births — deliveries without medical intervention — that persisted even when clinical circumstances clearly warranted otherwise. As Ockenden concluded, the quest for normal birth continued even as warning signs mounted around individual patients. Families who repeatedly requested caesarean sections were denied them, in some cases multiple times.
Women in labor arrived at the hospital seeking urgent help, only to be turned away regardless of whether they were in the early or advanced stages of labor. Others begged for pain relief that was never provided. Some gave birth alone, without any medical support present.
Voices Dismissed and Concerns Ignored
The report identified a consistent pattern of families whose voices were disregarded, whose accounts were treated with skepticism, and whose legitimate concerns were downplayed by medical staff. Mothers who raised alarms about their babies’ movements or lack of growth were told by staff they were anxious and imagining it.
Staff members were at times described in the report as “cruel,” with women in labor told to pull themselves together or wait their turn. According to the review, hospital bosses brushed warnings under the carpet rather than acting on concerns raised by staff and families. Women’s pleas for help were systematically ignored, creating an environment where dangerous practices continued unchecked for years.
In a separate, deeply troubling incident, an early gestation baby’s body was inadvertently disposed of as clinical waste by laboratory staff following a post-mortem examination. Days before the report’s release, Nottinghamshire Police arrested two men, aged 55 and 59, on suspicion of Misconduct in a Public Office as part of Operation Perth, its criminal investigation into mortuary service practices at Queen’s Medical Centre and Nottingham City Hospital. Police said they had uncovered breaches of the Human Tissue Act relating to the management and operating practices of the mortuary services.
Families Demand Full Public Inquiry
Families, including those of Gary and Sarah Andrews, parents of Wynter Andrews, and Jack and Sarah Hawkins, parents of Harriet Hawkins, were among those caught up in the scandal. For Jack and Sarah Hawkins, who have campaigned for accountability since their daughter Harriet’s death in 2016, the government response fell short. The couple said they had “zero faith” any changes would be implemented without a full public inquiry.
In a solemn show of solidarity following the report’s release, Nottingham families gathered to observe a minute of silence, honouring those who lost their lives.
The government moved swiftly to announce its first concrete response, committing to extend Martha’s Rule to all maternity and neonatal settings in England — giving parents the right to demand a rapid independent review if they believe a mother’s or baby’s condition is deteriorating and their concerns are being ignored. Health Secretary James Murray described the findings as devastating and said a full government response to Ockenden’s national recommendations would follow in September. Pressed on whether a full statutory public inquiry would be ordered, Murray said nothing was off the table.
Ockenden stated that training midwives as nurses first is “absolutely worth considering” and that midwives had told her they didn’t feel “ready” by the time they entered the profession and did “not believe they have the skills to care for today’s complex women.” Since the 1990s, the United Kingdom has allowed midwives to qualify without training as a nurse beforehand, meaning students could specialise from age 18.
The Nottingham scandal follows Ockenden’s earlier inquiry into maternity care at the Shrewsbury and Telford Hospital NHS Trust, which exposed comparable patterns of neglect, raising urgent questions about whether the failures uncovered in Nottingham reflect a broader cultural problem within parts of the NHS.
For the families who spent years fighting to be heard — families who were told their grief was unfounded, their instincts wrong, their pleas inconvenient — the publication of the report represents a hard-won moment of truth. The review gives official acknowledgment to suffering that was real, preventable and inexcusable. For 156 children and six mothers, however, it comes far too late.
